Non-Member: Preliminary Consultation Questions

Respondent Information

Question Title

* 1. Contact

First Name

Last Name

Email Address

Phone Number

Question Title

* 2. I am a

Medical Student

Resident

Staff Physician

Other (please specify)

Question Title

* 3. Gender

Female

Male

Gender Diverse

Prefer not to disclose

Question Title

* 4. Which race category best describes you? Check all that apply:

Black (African, Afro-Caribbean, African Canadian descent)

East/Southeast Asian (Chinese, Korean, Japanese, Taiwanese descent or Filipino, Vietnamese, Cambodian, Thai, Indonesian, other Southeast Asian descent

Indigenous (First Nations, Métis, Inuk/Inuit)

Latino (Latin American / Hispanic descent)

Middle Eastern (Arab, Persian, West Asian descent (e.g., Afghan, Egyptian, Iranian, Lebanese, Turkish, Kurdish)

South Asian South Asian descent (e.g., East Indian, Pakistani, Bangladeshi, Sri Lankan, Indo-Caribbean)

White European descent

Another race category (Includes values not described above or Do not know, not applicable, prefer not to answer)

Question Title

* 5. Province or Territory of Practice (select all that apply)

Alberta

British Columbia

Manitoba

New Brunswick

Newfoundland and Labrador

Nova Scotia

Ontario

Prince Edward Island

Quebec

Saskatchewan

Yukon

Northwest Territories

Nunavut

I practice outside of Canada

Question Title

* 6. If you are a staff physician, how many years have you been practicing

1-5

6-15

16-25

25+

Question Title

* 7. Certification/training stream

CCFP

CCFP(EM)

FRCPC

Other (please specify)

Question Title

* 8. Location of practice (select all that apply)

Urban Community

Urban Academic

Rural, Remote or Small Urban (population less than 30,000 people)

Non-Member: Preliminary Consultation Questions

Respondent Information

Question Title

* 1. Contact

Question Title

* 2. I am a

Question Title

* 3. Gender

Question Title

* 4. Which race category best describes you? Check all that apply:

Question Title

* 5. Province or Territory of Practice (select all that apply)

Question Title

* 6. If you are a staff physician, how many years have you been practicing

Question Title

* 7. Certification/training stream

Question Title

* 8. Location of practice (select all that apply)

Question Title

* 9. Type of practice (i.e. in your practice location what is the scope of your practice)

Question Title

* 10. I am not currently a CAEP member because:

Question Title

* 11. I would like to join/renew with CAEP:

Question Title

* 12. I would like to participate in an interview style consultation